What is culture change?

An interview with by Sue Misiorski, Culture Change Specialist with the Paraprofessional Healthcare Institute

Across the United States, a growing number of long term care agencies are embracing the philosophy and values of “culture change.” The consumers, staff, and other stakeholders associated with these agencies are on a journey to transform the organizational culture in order to transfer primary decision making back to the consumer and those who work closest with them. While the culture change movement encompasses the entire continuum of long term care, this article will focus on transformation within the nursing home setting; a transformation with the goal of creating all the elements of home inside a typically institutional environment.

Culture and Culture Change

In long-term care, organizational cultures are complex, encompassing system-wide attitudes, values, and practices that influence how people live and work together. Consider this definition of culture:

A culture is a pattern of shared basic assumptions that have been learned by the members of their group. These assumptions stem from people’s experience, as they conduct their business over and over again. Cultural assumptions provide meaning to daily events for people inside a group; they make life predictable and therefore reduce anxiety. They are taught (in both explicit and tacit ways) to new group members as the “correct” way to perceive, think, and feel about all aspects of daily life.

These underlying cultural assumptions (which become norms) influence an organization’s ability to implement and sustain a person-directed culture.

In most nursing homes, the pervasive culture is institution-centered. The norms that govern daily activity are influenced by the hospital/industrial model of care, placing the locus of control with the facility leadership. This approach conceives of residents as patients who are sick and unable to care for themselves; daily practices are organized for the efficient operation of the facility, rather than the physical, social, and spiritual needs of the residents. The overall design and operating procedures are similar to those in hospitals. While the hospital/industrial model may be appropriate in an acute care setting, it is clearly not intended for places where people live.

The institution-centered culture is seen in virtually all aspects of daily life in traditional nursing homes. Examples include:

• Residents must eat at mealtimes set by the facility.
• Pre-served meals are delivered on hospital trays.
• Snacks (nourishments) are offered at 10 a.m., 2 p.m., and 8 p.m.
• Residents have little access to the outdoors or the city or town outside the nursing home.
• Residents are taken to the bathroom in prescheduled two-hour increments.
• Baths or showers are given twice per week according to facility policy and assignment of certified nursing assistants (CNAs).
• Staff decide when residents get up and return to bed.
• Residents are seen as passive recipients of services.
• Staff rotate, caring for different residents on a routine basis
• Staff have little involvement in decision making

These institution-centered practices, most of which would never be found in someone’s home, have existed for so long in nursing homes that they seem normal to those who work there—such practices are rarely questioned or even noticed. In many instances, individuals who live in nursing homes have learned to adjust to these routines and have accepted that this is just the way things operate there.

In addition to daily practices and the underlying values and assumptions that support them, objects are a telling aspect of any culture. The nursing home environment is filled with objects—shower chairs, hospital trays, call bells, and nourishment carts—not found in private homes. Similarly, institution-centered cultures have their own language, using words like “facility” instead of “home,” or “nourishment” instead of “snack.” Because people who live there are perceived by their illnesses, the simplest activities are referred to as “therapy.” Listening to music is “music therapy.” Petting a dog is “pet therapy.” All of these “therapies” occur at times set by the institution.

Unlike an institution-centered culture, a person-directed culture places the resident and his or her direct care workers at the center of the organizational structure. Residents are known as individuals and they dictate their care and daily life through verbal and nonverbal communication. Direct-care workers (usually certified or licensed nursing assistants) have consistent assignments and are highly involved in decision making and care planning. The locus of control shifts from managers to residents and those who work closest with them; systems are designed to promote independence and individuality in the context of strong caregiving relationships and shared community. The ultimate goal is to nurture the spirit while also ensuring excellent medical care.

To create a comfortable environment, the person-directed nursing home is filled with objects that are familiar and reflect a feeling of home. Activities occur spontaneously, diminishing boredom and helplessness. Direct-care staff take on new roles, supporting residents in their continued growth and development. As the environment changes, so does the language used to describe places and objects: the “nourishment room” may be called the “pantry,” and the “lounge” may become the “family room.”

Examples of practices in an organization with a person-directed culture include:

• Food is accessible to residents at all times.
• Food is served family style at kitchen or dining room tables.
• Residents have consistent caregivers who know them as individuals.
• Residents’ rooms are filled with personal belongings.
• Activities occur spontaneously in addition to planned events.
• Residents direct the decisions affecting their lives in the home.
• Workers are empowered to listen and respond to residents needs. For example, if a resident is scheduled to have a shower one day but does not want it, the worker can give the shower another day.
• Residents live in neighborhoods or households staffed with empowered teams of caregivers and other supporting personnel. Decisions once made by facility managers are made at the household level.
• Residents are actively involved in all aspects of daily life, continuing to perform household functions such as cooking or cleaning if they desire.

This change in the organization of daily life requires that direct-care workers, traditionally toward the bottom of the staff hierarchy in a long-term care facility, have a great deal more decision-making authority and deeper engagement with residents. To ensure that residents are able to thrive, relationships with the workers who support them must be nourished and sustained. Thus, direct-care workers, who know the residents most intimately, are involved in care planning and have the flexibility and authority to respond to individual and collective resident needs—in fact they are expected to do so. In addition, as members of the household-based team, direct-care workers share responsibility for scheduling, budgets, supplies, quality outcomes, and so on, taking responsibility for ensuring that residents experience not only high-quality care but an enriching environment that sustains a high quality of life.

The pursuit of person-directed practices in long-term care organizations requires profound change from conventional practices that have sometimes been in place for years. Virtually every system with an impact on the residents’ experience in the nursing home—from personal care to personnel policies--must be reshaped to reflect this new philosophy of care. To begin the change process, providers need to explore their current organizational culture, including organizational values, norms, and artifacts. This exploration will help staff evaluate how their own organization’s culture promotes or hinders the ability of residents to live their lives as fully as possible.

Why Culture Change?

It is very difficult to look at long-term care objectively while working in the system day-to-day. Many talented people have dedicated their lives to caring for elders and people living with disabilities, both inside and outside the walls of the institution. These caregivers often refer to their careers as a “calling,” entering into their work with loving hearts and the desire to make a difference in people’s lives. Asking dedicated people to accept that this system is an overwhelming failure is not easy—yet that is what the culture change movement calls upon us to do.

So, why has the system failed? In the bluntest terms, most nursing homes offer a product that no one wants. In fact, many in the United States fear needing even the shortest stay in such institutional environments. These fears are so profound that millions of adults have stated they would rather die than live in a traditional nursing home. Perhaps this is because somehow, despite good intentions, the existing systems deny individuals in many nursing homes even the most basic human rights. This is harsh language, but it reflects the truth.

In many nursing homes, disempowerment goes well beyond activities of daily living. Doors are alarmed to prevent anyone from going outside, residents with nothing to do are lined up in hallways and at the nursing station, and a person needing a restroom risks incontinence while waiting for a staff person to assist. These examples illustrate how current practices make people who are frail or living with a disability feel impotent. In order to receive the care they need, residents forfeit their rights to control basic aspects of their daily lives.

Perhaps the system is a failure because we ask people to live in environments that rarely feel like home. Most nursing home buildings have been designed to efficiently provide standardized care to large numbers of people. Individuals often have multiple roommates and lack even the smallest space to call their own. Outside their rooms, long institutional hallways stem off a central nursing station. The sounds of call bells, personal chair alarms, and overhead paging are constant reminders to residents that they no longer live in their own homes.

Perhaps the system is a failure because the current culture contributes to an average annual Nursing Assistant turnover rate of 71 percent nationally. Direct-care workers cite heavy workloads, lack of teamwork, lack of communication, and the inability to earn a living wage as sources of significant job-related stress. But most importantly, direct-care workers choose this work because they enjoy the relationships at the heart of long-term care. When traditional long-term care environments fail to nurture those relationships, many leave the field, finding few other intrinsic rewards. This is particularly painful for consumers who inevitably cite the consistency and quality of their relationships with their caregivers as the critical factor in determining their quality of life.

There is an undeniable negative impact of the current system on both residents and staff. In order to improve the overall culture a radical change is needed: a change that improves both the quality of jobs and the quality of care. People who live and work in long-term care have inherited the existing system, often not questioning its limits. Our responsibility now, however, is to accept the overwhelming failure of the system and to establish a passionate sense of urgency about transforming it. The good news is that, in pockets all over the nation, people who understand this urgent need for transformation have already been making radical changes in traditional residential care environments. Homes that have been implementing culture change practices for three years or longer are reporting exciting results. These include decreased incidents of depression, increased time in social interaction, improved nutritional health, lower resident mortality and greater staff retention. Culture change can-and is—making a difference.

To find out more about the movement to transform long-term care, visit the Pioneer Network and the National Clearinghouse on the Direct Care Workforce.